Environmental Information Worksheet
(Use attachments where more space is required)
1. Water System Owner
2. Needs and Alternatives - Provide a brief narrative that describes:
a. Current drinking water system needs.
b. Project alternatives not selected and their potential environmental impacts.
3. Description
a. Give a description of the proposed project and auxiliary facilities.
b. Indicate construction methods, timing, and duration which might temporarily impact the
environment.
Updated 10-19-12
4. Project Location
County
City / Township
¼
¼ Section
Township
Range
Attach Copies of each of the following:
a. Copy of U.S. Geological Survey 7.5 minute, 1:24,000 scale map or equivalent
(photocopy is acceptable) indicating the project boundaries;
b. site plan showing all significant project and natural features; and
c. If needed for clarification, a county map showing the general location of project.
5. Project Magnitude Data
Total project area (acres)
and/or total
and/or length (feet or miles)
square feet.
6. Permits and Approvals Required
List all known local, state, and federal permits, approvals and funding required.
Unit of Government
Type of Application
Status
7. Land Use
Describe current and recent past due land use and development on the site and on adjacent
lands. Discuss project compatibility with adjacent and nearby land uses. Indicate whether and
potential conflicts involve environmental matters. Identify and potential environmental
hazard due to past land uses, such as soil contamination or abandoned storage tanks or
proximity to nearby hazardous liquid or gas pipelines.
8. Cover Types
Estimate the acreage of the site with each of the following cover types before and after
development (before and after totals should be equal):
Before
After
Type 1 to 8 Wetlands
Wooded / Forest
Brush / Grassland
Crop Land
Lawn / Landscaping
Impervious Surface
Other (describe)
9. Fish, Wildlife and Ecologically Sensitive Resources
a. Identify fish and wildlife resources on or near the site and discuss how they would be
affected by the project. Describe any measures to be taken to minimize or avoid adverse
impacts.
b. Are any state listed endangered, threatened or special-concern species; rare plant
communities or other sensitive ecological resource such as native prairie habitat, colonial
waterbird nesting colonies or regionally rare plant communities on or near the site?
Yes
No
If yes, describe the resource and how it would be affected by the project. Indicate if a site
survey of the resources was conducted and describe the results. Describe measure to be
taken to minimize or avoid adverse impacts.
10. Physical Impacts on Water Resources
Will the project involve the physical or hydrologic alteration (dredging, filling, stream
diversion, outfall structure, diking, and impoundment) of any surface water (lake, pond,
wetland, stream, drainage ditch)?
Yes
No
If yes, identify water resources affected and give the Minnesota Department of Natural
Resources (DNR) Protected Waters Inventory number(s) if the water resources affected are
on the PWI:
. Describe alternatives considered and proposed mitigation measures
to minimize impacts.
11. Water Use
a. Will the project involve the installation or abandonment of any wells?
Yes
No
b. Will the project require an appropriation of ground or surface water (including
dewatering)?
Yes
No
If yes, indicate the source, quantity, duration, purpose of the appropriation, and the DNR
water appropriation permit number of any existing appropriation. Discuss the impact of
the appropriation on ground water levels.
12. Water-related Land Use Management Districts
Does any part of the project site involve a shoreland zoning district, a delineated 100-year
flood plain or a state or federally designated wild or scenic river land use district?
Yes
No
If yes, identify the district and discuss the compatibility of the project with the district land
use regulations.
13. Erosion and Sedimentation
Give the acreage to be graded or excavated and cubic yards of soil to be moved:
acres;
cubic yards.
Describe any steep slopes or highly erodible soils and identify the on the site map. Describe
the erosion and sedimentation measures to be used during and after construction of the
project.
14. Water Quality – Surface Water Runoff
a. Compare the quantity and quality of site runoff before and after the project. Describe
methods to be used to manage or treat runoff. Describe any stormwater pollution
prevention plans.
b. Identify route(s) and receiving water bodies for runoff from the site. Estimate the impact
of runoff on the quality of receiving waters.
15. Water Quality – Wastewaters
a. Describe sources, quantities and composition (except for normal domestic sewage) of all
sanitary and industrial waterwaters produced or treated at the site.
b. Describe waste treatment methods or pollution prevention efforts and give estimates of
composition after treatment. Identify receiving waters, including major downstream
water bodies and estimate the discharge impact on the quality of the receiving waters. If
the project involves on-site sewage systems, discuss the suitability of site condition.
c. If wastes will be discharged into a publically owned treatment facility’s ability to handle
the volume and composition of wastes. Identify any improvements necessary.
16. Geological Hazards and Soil Conditions
a. Approximate depth (in feet) to:
ground water:
minimum:
average:
bedrock:
minimum:
average:
b. Describe any of the following geological site hazards to ground water and also identify
them on the site map: sinkholes, shallow limestone formations or karst conditions.
Describe measures to avoid or minimize environmental problems due to any of these
hazards.
c. Describe the soils on the site, giving Soil Conservation Service classifications, if known.
Discuss soil granularity and potential for groundwater contamination from wastes or
chemicals spilled on the soils. Discuss mitigation measures to prevent contamination.
17. Solid Wastes; Hazardous Wastes; Storage Tanks
a. Describe types, amounts and composition of solid or hazardous wastes, including sludge
and ash. Identify method and location of disposal. For projects generating municipal solid
waste, indicating if there will be a source separation plan. If hazardous waste is generated
indicate if there is a hazardous waste minimization plan and routine hazardous waste
reduction assessments.
b. Identify any toxic or hazardous materials to be used or present at the site and identify
measures to be used to prevent them from contaminating groundwater.
c. Indicate the number, location, size and use of any above or below ground tanks to store
petroleum products or other materials (except water).
18. Stationary Source Air Emissions
Will the project involve any stationary sources of air emissions (such as boilers or exhaust
stack)?
Yes
No
If yes, describe the sources, quantities and composition of the emissions; the proposed air
pollution control devices; the quantities and composition of the emissions after treatment and
the effects on air quality.
19. Odor, Noise and Dust
Will the project generate dust, odors or noise during construction and/or operation?
Yes
No
If yes, describe sources, characteristics, duration, quantities or intensity and any proposed
measures to mitigate adverse impacts. Also, identify locations of nearby sensitive receptors
and estimate impacts on them.
20. Resources
Are any of the following resources on or in proximity to the site:
a. Archaeological, historical or architectural resources?*
Yes
No
b. Prime or unique farmlands or land within an agricultural preserve? Yes
No
c. Designated parks, recreation areas or trails?
Yes
No
d. Scenic views and vistas?
Yes
No
e. Other unique resources?
Yes
No
*Any project requiring an environmental review must state in the solicitation letter to the
State Historic Preservation Office (SHPO) that a National Historic Preservation Act Section
106 review is required. A copy of the solicitation letter to SHPO must be provided. If it is
determined that any historic sites or structures will be impacted, an agreement must be
reached with the State Historic Preservation Office, MDH, and the project submitter before
funding can be received. A copy of the agreement must be attached.
If yes, describe the resource and identify any project-related impacts on the resources.
Describe any measures to minimize or avoid adverse impacts.
21. Compatibility with Plans
Is this project subject to an adopted local comprehensive plan, land use plan or regulation or
other applicable land use, water or resource management plan of a local, regional, state or
federal agency?
Yes
No
If yes, describe the plan, discuss its compatibility with the project and explain how any
conflicts will be resolved. If no, explain.
22. Impact on Infrastructure and Public Services
Will new or expanded utilities, roads, other infrastructure or public services be required to
serve the project?
Yes
No
If yes, describe the new or additional infrastructure or services needed.
23. Related Developments; Cumulative Impacts
a. Are future stages of this development planned or likely?
Yes
No
If yes, briefly describe future stages, their timing and plans for environmental review.
b. Is this project a subsequent stage of an earlier project?
Yes
No
If yes, briefly describe the past development, its timing and any past environmental
review.
c. Is this development anticipated on adjacent land?
Yes
No
If yes, briefly describe the development and its relationship to the present project.
24. Other potential Environmental Impacts
If the project may cause any adverse environmental impacts not addressed in Items 1 through
23 on this worksheet, identify and discuss them here, along with any proposed mitigation.
25. Summary of Issues
List any impacts and issues identified that may require further investigation before the
project is begun. Discuss any alternatives or mitigative measures that have been or may be
considered for these impacts and issues, including those that have been or may be ordered as
permit conditions.
Updated 10-19-12